|
Thalassemia & Hemoglobinopathy Comprehensive
|
Professional
|
Both
|
$99.27
|
|
|
Service Code
|
CPT 82728
|
| Hospital Charge Code |
4254047
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$98.08 |
| Rate for Payer: Aetna Commercial |
$98.08
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$88.79
|
| Rate for Payer: Aetna Managed Medicare |
$14.18
|
| Rate for Payer: Anthem Medicare Advantage |
$14.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.18
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.18
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cash Price |
$29.78
|
| Rate for Payer: Cigna Commercial |
$98.08
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$51.62
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.18
|
| Rate for Payer: Health EOS Commercial |
$93.95
|
| Rate for Payer: HFN Commercial |
$98.08
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$50.03
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$50.03
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.18
|
| Rate for Payer: Multiplan Commercial |
$82.59
|
| Rate for Payer: NAPHCARE Commercial |
$21.26
|
| Rate for Payer: Preferred Network Access Commercial |
$98.08
|
| Rate for Payer: Quartz Beloit One Network |
$45.43
|
| Rate for Payer: Quartz Commercial |
$58.85
|
| Rate for Payer: Quartz Medicare Advantage |
$14.18
|
| Rate for Payer: The Alliance Commercial |
$55.99
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.18
|
| Rate for Payer: WEA Trust Commercial |
$56.78
|
| Rate for Payer: WPS Commercial |
$62.37
|
|
|
Thalass Interp
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$18.78
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$70.43
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$32.87
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$31.18
|
| Rate for Payer: Anthem Medicare Advantage |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.78
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$18.78
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$75.08
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$18.78
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$69.87
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$18.78
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.78
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$18.78
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$28.17
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$87.20
|
| Rate for Payer: Quartz Medicare Advantage |
$18.78
|
| Rate for Payer: The Alliance Commercial |
$75.13
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.78
|
| Rate for Payer: United Healthcare PPO |
$100.62
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: Wellcare Medicare |
$18.78
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Thalass Interp
|
Professional
|
Both
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.78 |
| Max. Negotiated Rate |
$127.45 |
| Rate for Payer: Aetna Commercial |
$127.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Aetna Managed Medicare |
$18.78
|
| Rate for Payer: Anthem Medicare Advantage |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$18.78
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$18.78
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$127.45
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$67.08
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$18.78
|
| Rate for Payer: Health EOS Commercial |
$122.09
|
| Rate for Payer: HFN Commercial |
$127.45
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$66.30
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$66.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$18.78
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: NAPHCARE Commercial |
$28.17
|
| Rate for Payer: Preferred Network Access Commercial |
$127.45
|
| Rate for Payer: Quartz Beloit One Network |
$59.03
|
| Rate for Payer: Quartz Commercial |
$76.47
|
| Rate for Payer: Quartz Medicare Advantage |
$18.78
|
| Rate for Payer: The Alliance Commercial |
$74.19
|
| Rate for Payer: United Healthcare Medicare Advantage |
$18.78
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$82.64
|
|
|
Thalass Interp
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
CPT 83021
|
| Hospital Charge Code |
4254086
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$65.74 |
| Max. Negotiated Rate |
$123.43 |
| Rate for Payer: Aetna Commercial |
$120.74
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$115.38
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$71.10
|
| Rate for Payer: Cash Price |
$38.70
|
| Rate for Payer: Cigna Commercial |
$123.43
|
| Rate for Payer: Health EOS Commercial |
$119.40
|
| Rate for Payer: HFN Commercial |
$123.43
|
| Rate for Payer: Multiplan Commercial |
$107.33
|
| Rate for Payer: Preferred Network Access Commercial |
$123.43
|
| Rate for Payer: Quartz Beloit One Network |
$65.74
|
| Rate for Payer: Quartz Commercial |
$80.50
|
| Rate for Payer: WEA Trust Commercial |
$73.79
|
| Rate for Payer: WPS Commercial |
$99.37
|
|
|
Thallium-201(per mCi)
|
Professional
|
Both
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$126.46 |
| Rate for Payer: Aetna Commercial |
$126.46
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$126.46
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$79.87
|
| Rate for Payer: Health EOS Commercial |
$121.14
|
| Rate for Payer: HFN Commercial |
$126.46
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.36
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$126.46
|
| Rate for Payer: Quartz Beloit One Network |
$58.57
|
| Rate for Payer: Quartz Commercial |
$75.88
|
| Rate for Payer: The Alliance Commercial |
$66.56
|
| Rate for Payer: United Healthcare Medicaid |
$34.12
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Thallium-201(per mCi)
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$61.15 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$74.88
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
Thallium-201(per mCi)
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.23 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$79.87
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Thallium-201(per mCi)
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.94 |
| Max. Negotiated Rate |
$114.82 |
| Rate for Payer: Aetna Commercial |
$112.32
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Aetna Managed Medicare |
$34.94
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$81.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$62.40
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$59.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$66.14
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$114.82
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$69.84
|
| Rate for Payer: Health EOS Commercial |
$111.07
|
| Rate for Payer: HFN Commercial |
$114.82
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$93.60
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: NAPHCARE Commercial |
$74.88
|
| Rate for Payer: Preferred Network Access Commercial |
$114.82
|
| Rate for Payer: Quartz Beloit One Network |
$61.15
|
| Rate for Payer: Quartz Commercial |
$81.12
|
| Rate for Payer: Quartz Medicare Advantage |
$74.88
|
| Rate for Payer: The Alliance Commercial |
$62.40
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
Thallium-201(per mCi)
|
Professional
|
Both
|
$120.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
5381842
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.12 |
| Max. Negotiated Rate |
$118.56 |
| Rate for Payer: Aetna Commercial |
$118.56
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$107.33
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cigna Commercial |
$118.56
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$34.12
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.88
|
| Rate for Payer: Health EOS Commercial |
$113.57
|
| Rate for Payer: HFN Commercial |
$118.56
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$55.36
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$55.36
|
| Rate for Payer: Multiplan Commercial |
$99.84
|
| Rate for Payer: Preferred Network Access Commercial |
$118.56
|
| Rate for Payer: Quartz Beloit One Network |
$54.91
|
| Rate for Payer: Quartz Commercial |
$71.14
|
| Rate for Payer: The Alliance Commercial |
$62.40
|
| Rate for Payer: United Healthcare Medicaid |
$34.12
|
| Rate for Payer: WEA Trust Commercial |
$68.64
|
| Rate for Payer: WPS Commercial |
$92.44
|
|
|
Thallium-201(per mCi)
|
Facility
|
OP
|
$128.00
|
|
|
Service Code
|
HCPCS A9505
|
| Hospital Charge Code |
1486854
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.27 |
| Max. Negotiated Rate |
$122.47 |
| Rate for Payer: Aetna Commercial |
$119.81
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$114.48
|
| Rate for Payer: Aetna Managed Medicare |
$37.27
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$86.53
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$66.56
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$63.90
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$70.55
|
| Rate for Payer: Cash Price |
$38.40
|
| Rate for Payer: Cigna Commercial |
$122.47
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$74.50
|
| Rate for Payer: Health EOS Commercial |
$118.48
|
| Rate for Payer: HFN Commercial |
$122.47
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$99.84
|
| Rate for Payer: Multiplan Commercial |
$106.50
|
| Rate for Payer: NAPHCARE Commercial |
$79.87
|
| Rate for Payer: Preferred Network Access Commercial |
$122.47
|
| Rate for Payer: Quartz Beloit One Network |
$65.23
|
| Rate for Payer: Quartz Commercial |
$86.53
|
| Rate for Payer: Quartz Medicare Advantage |
$79.87
|
| Rate for Payer: The Alliance Commercial |
$66.56
|
| Rate for Payer: WEA Trust Commercial |
$73.22
|
| Rate for Payer: WPS Commercial |
$98.60
|
|
|
Thawing Fee
|
Facility
|
IP
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$24.97 |
| Max. Negotiated Rate |
$46.88 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$30.58
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Thawing Fee
|
Professional
|
Both
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$22.42 |
| Max. Negotiated Rate |
$71.19 |
| Rate for Payer: Aetna Commercial |
$48.41
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$48.41
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$25.48
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$30.58
|
| Rate for Payer: Health EOS Commercial |
$46.37
|
| Rate for Payer: HFN Commercial |
$48.41
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$71.19
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$71.19
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: Preferred Network Access Commercial |
$48.41
|
| Rate for Payer: Quartz Beloit One Network |
$22.42
|
| Rate for Payer: Quartz Commercial |
$29.05
|
| Rate for Payer: The Alliance Commercial |
$25.48
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Thawing Fee
|
Facility
|
OP
|
$49.00
|
|
|
Service Code
|
CPT 86927
|
| Hospital Charge Code |
2949311
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$24.46 |
| Max. Negotiated Rate |
$717.18 |
| Rate for Payer: Aetna Commercial |
$45.86
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$43.83
|
| Rate for Payer: Aetna Managed Medicare |
$179.30
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$33.12
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.46
|
| Rate for Payer: Anthem Medicare Advantage |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$27.01
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$179.30
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$179.30
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: Cigna Commercial |
$46.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$179.30
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$28.52
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$179.30
|
| Rate for Payer: Health EOS Commercial |
$45.35
|
| Rate for Payer: HFN Commercial |
$46.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$666.98
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$179.30
|
| Rate for Payer: Independent Care Health Plan Medicare |
$179.30
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$179.30
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$179.30
|
| Rate for Payer: Multiplan Commercial |
$40.77
|
| Rate for Payer: NAPHCARE Commercial |
$268.94
|
| Rate for Payer: Preferred Network Access Commercial |
$46.88
|
| Rate for Payer: Quartz Beloit One Network |
$24.97
|
| Rate for Payer: Quartz Commercial |
$33.12
|
| Rate for Payer: Quartz Medicare Advantage |
$179.30
|
| Rate for Payer: The Alliance Commercial |
$717.18
|
| Rate for Payer: United Healthcare Medicare Advantage |
$179.30
|
| Rate for Payer: United Healthcare PPO |
$38.22
|
| Rate for Payer: WEA Trust Commercial |
$28.03
|
| Rate for Payer: Wellcare Medicare |
$179.30
|
| Rate for Payer: WPS Commercial |
$37.74
|
|
|
Theophylline Level
|
Professional
|
Both
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$345.80 |
| Rate for Payer: Aetna Commercial |
$345.80
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$14.71
|
| Rate for Payer: Anthem Medicare Advantage |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.71
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$345.80
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$182.00
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$14.71
|
| Rate for Payer: Health EOS Commercial |
$331.24
|
| Rate for Payer: HFN Commercial |
$345.80
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$51.91
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$51.91
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.06
|
| Rate for Payer: Preferred Network Access Commercial |
$345.80
|
| Rate for Payer: Quartz Beloit One Network |
$160.16
|
| Rate for Payer: Quartz Commercial |
$207.48
|
| Rate for Payer: Quartz Medicare Advantage |
$14.71
|
| Rate for Payer: The Alliance Commercial |
$58.09
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.71
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$64.70
|
|
|
Theophylline Level
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.71 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Aetna Managed Medicare |
$14.71
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$55.15
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$25.73
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$24.41
|
| Rate for Payer: Anthem Medicare Advantage |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$14.71
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$14.71
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$14.71
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$203.70
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$14.71
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$54.70
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$14.71
|
| Rate for Payer: Independent Care Health Plan Medicare |
$14.71
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$14.71
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$14.71
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: NAPHCARE Commercial |
$22.06
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$236.60
|
| Rate for Payer: Quartz Medicare Advantage |
$14.71
|
| Rate for Payer: The Alliance Commercial |
$58.82
|
| Rate for Payer: United Healthcare Medicare Advantage |
$14.71
|
| Rate for Payer: United Healthcare PPO |
$273.00
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: Wellcare Medicare |
$14.71
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
Theophylline Level
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 80198
|
| Hospital Charge Code |
633839
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$178.36 |
| Max. Negotiated Rate |
$334.88 |
| Rate for Payer: Aetna Commercial |
$327.60
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$313.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$192.92
|
| Rate for Payer: Cash Price |
$105.00
|
| Rate for Payer: Cigna Commercial |
$334.88
|
| Rate for Payer: Health EOS Commercial |
$323.96
|
| Rate for Payer: HFN Commercial |
$334.88
|
| Rate for Payer: Multiplan Commercial |
$291.20
|
| Rate for Payer: Preferred Network Access Commercial |
$334.88
|
| Rate for Payer: Quartz Beloit One Network |
$178.36
|
| Rate for Payer: Quartz Commercial |
$218.40
|
| Rate for Payer: WEA Trust Commercial |
$200.20
|
| Rate for Payer: WPS Commercial |
$269.61
|
|
|
THERA BAND SILVER LATEX FREE 50 YARD #9254-23-06
|
Facility
|
IP
|
$1,830.00
|
|
| Hospital Charge Code |
2969904
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$932.57 |
| Max. Negotiated Rate |
$1,750.94 |
| Rate for Payer: Aetna Commercial |
$1,712.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,636.75
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.70
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,750.94
|
| Rate for Payer: Health EOS Commercial |
$1,693.85
|
| Rate for Payer: HFN Commercial |
$1,750.94
|
| Rate for Payer: Multiplan Commercial |
$1,522.56
|
| Rate for Payer: Preferred Network Access Commercial |
$1,750.94
|
| Rate for Payer: Quartz Beloit One Network |
$932.57
|
| Rate for Payer: Quartz Commercial |
$1,141.92
|
| Rate for Payer: WEA Trust Commercial |
$1,046.76
|
| Rate for Payer: WPS Commercial |
$1,409.65
|
|
|
THERA BAND SILVER LATEX FREE 50 YARD #9254-23-06
|
Facility
|
OP
|
$1,830.00
|
|
| Hospital Charge Code |
2969904
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$532.90 |
| Max. Negotiated Rate |
$1,750.94 |
| Rate for Payer: Aetna Commercial |
$1,712.88
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$1,636.75
|
| Rate for Payer: Aetna Managed Medicare |
$532.90
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$1,237.08
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$951.60
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$913.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$1,008.70
|
| Rate for Payer: Cash Price |
$549.00
|
| Rate for Payer: Cigna Commercial |
$1,750.94
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$1,065.06
|
| Rate for Payer: Health EOS Commercial |
$1,693.85
|
| Rate for Payer: HFN Commercial |
$1,750.94
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$1,427.40
|
| Rate for Payer: Multiplan Commercial |
$1,522.56
|
| Rate for Payer: NAPHCARE Commercial |
$1,141.92
|
| Rate for Payer: Preferred Network Access Commercial |
$1,750.94
|
| Rate for Payer: Quartz Beloit One Network |
$932.57
|
| Rate for Payer: Quartz Commercial |
$1,237.08
|
| Rate for Payer: Quartz Medicare Advantage |
$1,141.92
|
| Rate for Payer: The Alliance Commercial |
$951.60
|
| Rate for Payer: WEA Trust Commercial |
$1,046.76
|
| Rate for Payer: WPS Commercial |
$1,409.65
|
|
|
THERAPEUTIC DRUG MONITORING
|
Facility
|
OP
|
$14.41
|
|
|
Service Code
|
EAPG 00405
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$14.41 |
| Rate for Payer: Anthem Medicaid |
$13.86
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicaid HMO |
$13.86
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Medicaid |
$13.86
|
| Rate for Payer: Dean Health Medicaid |
$13.86
|
| Rate for Payer: Independent Care Health Plan Medicaid |
$13.86
|
| Rate for Payer: Managed Health Services Medicaid |
$14.41
|
| Rate for Payer: Molina Healthcare Medicaid |
$13.86
|
| Rate for Payer: Quartz Badgercare/Employee Trust Funds/QHP |
$13.86
|
| Rate for Payer: United Healthcare Medicaid |
$13.86
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
OP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$78.62 |
| Max. Negotiated Rate |
$362.96 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Aetna Managed Medicare |
$78.62
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$362.96
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$298.48
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$282.88
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$157.14
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$210.08
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: NAPHCARE Commercial |
$168.48
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$182.52
|
| Rate for Payer: Quartz Medicare Advantage |
$168.48
|
| Rate for Payer: The Alliance Commercial |
$140.40
|
| Rate for Payer: United Healthcare PPO |
$210.60
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
Therapeutic Exercise Charges ST
|
Facility
|
IP
|
$270.00
|
|
|
Service Code
|
CPT 97110 GN
|
| Hospital Charge Code |
753741
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$137.59 |
| Max. Negotiated Rate |
$258.34 |
| Rate for Payer: Aetna Commercial |
$252.72
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$241.49
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$148.82
|
| Rate for Payer: Cash Price |
$81.00
|
| Rate for Payer: Cigna Commercial |
$258.34
|
| Rate for Payer: Health EOS Commercial |
$249.91
|
| Rate for Payer: HFN Commercial |
$258.34
|
| Rate for Payer: Multiplan Commercial |
$224.64
|
| Rate for Payer: Preferred Network Access Commercial |
$258.34
|
| Rate for Payer: Quartz Beloit One Network |
$137.59
|
| Rate for Payer: Quartz Commercial |
$168.48
|
| Rate for Payer: WEA Trust Commercial |
$154.44
|
| Rate for Payer: WPS Commercial |
$207.98
|
|
|
Therapeutic Inj
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$73.63
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Therapeutic Inj
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3970747
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$58.91 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$92.04
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Therapeutic Injection sub or Intra 96372
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$58.91 |
| Max. Negotiated Rate |
$303.10 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Aetna Managed Medicare |
$75.77
|
| Rate for Payer: Anthem Blue Access PPO/Blue Traditional |
$79.77
|
| Rate for Payer: Anthem Blue Preferred/Blue Preferred Plus |
$61.36
|
| Rate for Payer: Anthem Blue Priority WI/Blue Priority X-WI |
$58.91
|
| Rate for Payer: Anthem Medicare Advantage |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage HMO |
$75.77
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Medicare Advantage PPO |
$75.77
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Cook Children's Health Plan (CCHP) Commercial |
$75.77
|
| Rate for Payer: Dean Health DHI/DHP/ASO |
$68.68
|
| Rate for Payer: Dean Health Medicare Advantage/Medicare Select |
$75.77
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Humana Commercial/EPO/HMO/POS/PPO |
$281.88
|
| Rate for Payer: Humana Medicare EPO/Medicare HMO/Medicare PPO |
$75.77
|
| Rate for Payer: Independent Care Health Plan Medicare |
$75.77
|
| Rate for Payer: Managed Health Services Medicare Advantage |
$75.77
|
| Rate for Payer: Molina Healthcare Medicare Advantage/Molina Marketplace |
$75.77
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: NAPHCARE Commercial |
$113.66
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$79.77
|
| Rate for Payer: Quartz Medicare Advantage |
$75.77
|
| Rate for Payer: The Alliance Commercial |
$303.10
|
| Rate for Payer: United Healthcare Medicare Advantage |
$75.77
|
| Rate for Payer: United Healthcare PPO |
$92.04
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: Wellcare Medicare |
$75.77
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
|
Therapeutic Injection sub or Intra 96372
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
CPT 96372
|
| Hospital Charge Code |
3382926
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$60.13 |
| Max. Negotiated Rate |
$112.90 |
| Rate for Payer: Aetna Commercial |
$110.45
|
| Rate for Payer: Aetna Gatekeeper/Not Gatekeeper |
$105.54
|
| Rate for Payer: Blue Cross Blue Shield of Illinois Blue Cross PPO |
$65.04
|
| Rate for Payer: Cash Price |
$35.40
|
| Rate for Payer: Cigna Commercial |
$112.90
|
| Rate for Payer: Health EOS Commercial |
$109.22
|
| Rate for Payer: HFN Commercial |
$112.90
|
| Rate for Payer: Multiplan Commercial |
$98.18
|
| Rate for Payer: Preferred Network Access Commercial |
$112.90
|
| Rate for Payer: Quartz Beloit One Network |
$60.13
|
| Rate for Payer: Quartz Commercial |
$73.63
|
| Rate for Payer: WEA Trust Commercial |
$67.50
|
| Rate for Payer: WPS Commercial |
$90.90
|
|
